Provider Demographics
NPI:1013496678
Name:SMART, RANDY D JR (ABOC, NCLEC, RDO)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:D
Last Name:SMART
Suffix:JR
Gender:M
Credentials:ABOC, NCLEC, RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 BROAD ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7186
Mailing Address - Country:US
Mailing Address - Phone:805-215-8571
Mailing Address - Fax:
Practice Address - Street 1:3840 BROAD ST STE 5
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7186
Practice Address - Country:US
Practice Address - Phone:805-787-0182
Practice Address - Fax:805-787-0150
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician